Behavioral economics represents a powerful, albeit underutilized tool by which to influence provider and systems behavior in a large-scale, meaningful, and sustainable way. We propose to use a sophisticated electronic health record (EHR) system to change the default choice for physicians to the choice most supported by clinical practice guidelines (CPG). We have selected two types of physician behaviors in one clinical area: prescribing HMG-CoA reductase inhibitors (statins) to patients with elevated cardiac risk and elevated low density lipoprotein cholesterol (LDL-C), and titrating statin dose to achieve LDL-C goals, both in step with cholesterol management guidelines. In a cluster randomized trial in a private, community-based multispecialty practice, we propose to compare usual care to a system of automated, default, opt-out clinical decision support that prescribes and titrates statins as appropriate. PUBLIC HEALTH RELEVANCE: Multiple guidelines exist describing best practices for effective interventions, yet a large gap persists between actual and optimal guideline compliance. The proposed study will examine the comparative effectiveness of an opt-out medication management protocol relative to usual care for patients not at goal, using national guidelines for cholesterol management implemented in a large multispecialty private practice that uses an Electronic Health Record system.